By: Kate Moran
Polio eradication is considered one of the 21st Century’s greatest medical successes. In 2009 fewer than 2,000 cases were reported worldwide. In 2012 that number decreased to only 223. Intensive national immunization programs in countries ranging from Peru to Japan are responsible for these figures, but organizations within the private sector, such as Rotary International, have also played an indispensable role. In 1985, Rotary launched PolioPlus, the first and largest internationally coordinated private-sector support of a public health initiative with an initial pledge of $120 million. By the year 2001, 575 million children in 94 countries, including 35 million in Afghanistan and Pakistan, and 16 million in conflict-affected countries in central Africa, were vaccinated. Despite these impressive figures, Afghanistan, Pakistan, and Nigeria, remain polio-endemic; that is, countries where polio is still an active and present threat to the population.
Polio is an issue deeply interwoven into the geopolitics of the developing world. In seeking to understand if and how polio can be eradicated once and for all, this article will examine the disease at it occurs in Afghanistan, Pakistan, and Nigeria. While there is no uniform model that can purport to act as a universal solution to solving the world’s public health issues, there are lessons that can be learned from each country.
Polio has a long history in Afghanistan as it has been ravaging villages and paralyzing children for decades, which much of the developed world has ignored. In 1988 the passage of a resolution by the World Health Assembly to eradicate polio by the year 2000, and the Global Polio Eradication Initiative was launched. Yet, Afghanistan remains a problem area in the fight to achieve polio eradication. Despite receiving cutting edge vaccination technologies (Afghanistan was the first country to use the bivalent oral polio vaccine in 2009), the country continues to suffer from outbreaks of the disease. Most documented cases originate in the southern provinces of the country, and habitually war-torn and politically divisive areas such as Helmand, Kandahar, and Uruzgan. In these areas, access to public health initiatives is severely restricted due to ongoing sectarian conflicts and political instability. These provinces, which have been under the control of the Taliban for a long time, comprise the poorest and most resource-starved region of the country. Southern Afghanistan, which shares a border with Pakistan, is also home to many refugees.
Following the Soviet invasion in 1979, many Afghanis fled to safer regions of the country or to neighboring countries. Many of these refugees were internally displaced when Pakistan began requiring refugees to return home. Due to a significant degree of activity and movement across the Afghan-Pakistan border, the poliovirus is more easily transmitted and harder to eradicate. The porous nature of the border causes frequent reinfection of both Pakistani and Afghan communities, with Afghanistan having the higher number of polio cases.
Pakistan, similar to Afghanistan, is a country plagued by geopolitical conflict and sectarian violence. An area particularly at risk for polio outbreaks is the Federally Administered Tribal Area (FATA), located along the country’s frontier with Afghanistan. It is an area of formidable terrain, and controlled by powerful warlords. In 2012, a Pakistani Taliban commander in Northern Waziristan, a province of the FATA, banned polio vaccinations after it was disclosed that the C.I.A. had staged a hepatitis vaccination campaign in its hunt for Osama bin Laden. The warlord, Hafiz Gul Bahadur, banned all efforts until American drone strikes ended. Despite only three children in the area contracting the virus since Bahadur’s ban on vaccination distribution, even solitary cases leave the entire country at risk and vulnerable to a widespread outbreak. Interestingly, Gul Bahadur’s actions were not consistent with the expressed views of the Afghan Taliban, which published a statement on its website two months ago about the importance of vaccinating children against polio. In fact, the Taliban has often collaborated with international immunization efforts by taking part in events such as the World Health Organization’s International Peace Day. On this day, Taliban factions in neighboring Afghanistan allow health workers access to children in provinces that are inaccessible due to violence and insurgency. In the past, the United Nations has been able to successfully negotiate week-long “polio ceasefires” in Afghanistan, enabling 35,000 health workers and volunteers to access more than 5 million children.
Since the ban on vaccinations in many parts of Northern Pakistan, thousands of children have been put at risk of contracting the virus. Health officials have voiced fears that the disease may become an epidemic and has the potential to spread to the neighboring regions if vaccination efforts are not resumed immediately. Currently, such efforts continue to be thwarted by local administrators. Pakistan’s geopolitics continue to be a major obstacle in achieving polio eradication. Until the Federally Administered Tribal Areas are brought under greater control by the country’s official government, and there is a considerable increase in Pakistan’s stability, polio is likely to continue presenting a threat to the nation’s health. The defeat of militant groups in the country would improve relations with Afghanistan; and concerted efforts by both countries to eliminate terrorism and return refugees to their homes would also be determining factors in the eventual eradication of the polio virus.
Nigeria is the third and final polio-endemic country in the world and the only country with ongoing transmission of all three serotypes: Wild Poliovirus Type 1, Wild Poliovirus Type 3, and Circulating Vaccine-derived Poliovirus Type 2. Northern states in the country are the main source of polio infections in Nigeria and in neighboring countries. Polio eradication efforts in Nigeria have been relatively slow due to unrest in various states and logistical complications, such as geographical remoteness and rugged terrain. In a study conducted in Borno State in 2005 among the Fulani (the dominant nomadic tribe in northern Nigeria) settlements, 99% of children surveyed had not received polio vaccine or other routine childhood vaccines. The CDC published a report in 2013 stating that “these communities reside in sparsely populated parts of Nigeria with no road access. In addition, the nomadic herders follow a seasonal pattern of movement with their cattle, with the result that many of the settlements are temporary. Such movements also increase the possibility that [polio] will be spread.”
Social and cultural barriers also inhibit health workers’ access to vulnerable communities. In northern Nigeria 2003 polio immunization campaigns were suspended following the spread of false rumors regarding the safety of the polio vaccine. Subsequently, a new polio outbreak occurred. This mishap reveals prevailing social and cultural norms, which include a distrust of Western and non-traditional medicines. However, recently the Nigerian government, along with international organizations and health agencies, has begun implementing programs to revitalize eradication efforts, and in doing so has gained better access to children in previously inaccessible areas of the country. Together with local health workers and community leaders, the Nigerian government’s polio initiative N-STOP, has been able to immunize more children than ever, including 11% in previously unreachable areas.
Shifting patterns of movement and migration, difficult natural terrain, poor infrastructure, prevailing cultural norms, and volatile political environments all contribute to the continued presence of the disease in Afghanistan, Pakistan, and Nigeria. While all of these factors certainly play a role and will continue to remain important in the fight to achieve polio eradication I believe that the greatest barrier to international efforts to eliminate the disease is geopolitics. Each of the aforementioned countries is considered a hotbed of militant activity, plagued by conflict and sectarian violence. As a result, the inhabitants of each have few resources and are subject to the whims of local tribal leaders and administrators. These isolated populations are unable to gain access to basic rights such as freedom from disease, which vaccinations play a significant role in preventing.
While each country is unique with different problems and cultures, the stability of these places determines in large part the health of its population. Therefore, it is in the interest of both international health organizations and national governments to seek political stability. This does not mean that such organizations should interfere in any way with a nation’s politics. Rather, they should collaborate with existing governments to achieve a greater degree of efficiency in implementing health policy in various communities. Polio eradication in Afghanistan, Pakistan, and Nigeria partially hinges upon the abilities of these countries to provide for the safety and security of its citizens. That is difficult as many of the vulnerable areas have been embroiled in decades of conflict and government ineffectiveness. Thus, polio eradication is truly an international effort, not just for health organizations, but for individuals and the concerted efforts of development agencies and organizations such as the United Nations and UNICEF.
If we want to achieve total worldwide eradication of polio, there must be greater concern for the everyday lives and needs of the people living in polio-infected countries: refugee resettlement efforts, community outreach, and clear and effective counterterrorism initiatives. I am not optimistic that polio will be eradicated in ten years, or even twenty. However, by the time my children or my grandchildren are grown, polio should be a thing of medical textbooks and historical experience.
Kate Moran, a junior at Emory, is a Middle Eastern/South Asian Studies and Arabic major. Her academic interests include international health and development, U.S. foreign policy in the Middle East, and refugee issues. Following her graduation in 2015, Kate intends to pursue a career in international development or academia.
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